Pyelonephritis and Complications of Pregnancy

1
Pyelonephritis and Complications of Pregnancy

• Byron D. Elliott, M.D.
• Medical Director of Perinatology
• Seton Medical Center

2
Pyelonephritis in PregnancyIncidence

• Occurs more commonly than any other medical
  problem in pregnancy
• Overall incidence is 1 - 2.5 in those receiving
  UNIVERSAL SCREENING and treatment of asymptomatic
  bacteriuria (ASB)
• As high as 40 of pregnancies with untreated ASB
  will develop pyelonephritis

3
Pyelonephritis in PregnancyRecurrence Risk

• Risk of recurrence in same pregnancy as high as
  10 -18 with suppressive therapy
• Recurrence as high as 60 if ongoing suppressive
  therapy is not employed

4
Pyelonephritis in PregnancyPredisposing Factors

• Physiologic changes of pregnancy
• Hydronephrosis, vesicoureteral reflux
• Increased bladder capacity, incomplete emptying
• Increased urine pH during pregnancy
• Coexistent factors
• Urinary anomalies, calculi, multiple UTIs
• Dehydration, poor hygiene
• Resistant organisms, Rx noncompliance
• Diabetes, Sickle disease

5
Pyelonephritis in PregnancyDiagnostic Criteria

• Clinical Findings
• Fever, chills, malaise
• CVA pain/tenderness, dysuria, frequency
• 50 unilateral right sided flank pain
• 25 bilateral or unilateral left sided pain
• Laboratory Findings
• Pyuria, bacteriuria
• White blood cell casts highly predictive
• Positive urine culture
• 10 20 bacteremic

6
Pyelonephritis in PregnancyDisease Categorization

• Mild / Moderate
• Low-grade Fever
• Normal or slightly elevated white blood cell
  count
• Absence of Nausea or Vomiting

• Severe
• High Fever
• Respiratory Insufficiency
• Poor urine output
• Sepsis
• Unable to tolerate oral intake or antibiotics
• No improvement during initial / observational
  phase

• Outpatient management after inpatient observation
  and initial parenteral Rx. can be considered with
  14 day oral antibiotic therapy

• Inpatient management is required

7
Pyelonephritis in PregnancyCommon pathogens

• Escherichia coli 70 80
• Klebsiella sp 3 7.4
• Staph aureus 6.7
• Proteus mirablis 2
• Gram positive (includes GBS) 10

8
Pyelonephritis in PregnancyInitial Management

• Inpatient observation
• Intravenous hydration, Lactated Ringers
• Strict I O, Maintain output gt30-50cc/hr
• Parenteral antibiotics
• Laboratory / Diagnostic Tests
• CBC, electrolytes, creatinine, urinalysis, urine
  culture and sensitivities
• CXR, pulse oximetry, ABGs if respiratory symptoms
  present

9
Pyelonephritis in PregnancyAntibiotic
Alternatives

• Parenteral
• Ceftriaxone 1-2gm q 24h
• Cefotetan 2gm q 12h
• Cefotaxime 1-2gm q 8h
• Ampicillin and 2gm q 6h
• Gentamycin 3-5mg/kg/day
• Ampicillin/Sulbactam 1.5gm q 6h
• Piperacillin/Tazobactam 3.75gm q 6-8h

10
Pyelonephritis in PregnancyAntibiotic
alternatives

• Oral
• Amoxicillin/Clavulanate 875/125mg BID
• Bactrim DS 160/800mg BID
• Suppression post-treatment
• Nitrofurantoin 100mg hs

11
Pyelonephritis in PregnancyComplications

• Multi-organ system involvement in 20
• Anemia due to hemolysis in up to 66
• DIC with severe sepsis
• Transient renal dysfunction in 20
• ARDS in 2 8, especially with
• Tachycardia gt110 BPM
• Fever gt103 in first 24 hours
• Fluid overload
• Tocolytic therapy
• Preterm Labor

12
Pyelonephritis in PregnancyPreterm Labor

• Treatment of Preterm labor in pyelonephritis with
  tocolytic therapy and steroids should be
  undertaken with great caution.
• Only for documented cervical change and regular
  uterine contractions unresponsive to hydration
  and parenteral antibiotics.
• Withholding tocolytics and/or steroids is
  appropriate in certain circumstances in patients
  with respiratory or hemodynamic instability.

13
Pyelonephritis in PregnancyFirst Trimester
Considerations

• Aggressive treatment with
• Cooling blanket
• Acetaminophen
• Maintain lower core temperature secondary to
  increased risk of fetal anomalies in high fever
  scenario

14
Pyelonephritis in PregnancySummary of Management

• Preventative Measures
• Universal screening for ASB
• Treatment of ASB
• Initial Treatment
• In-hospital observation for 24h
• Parenteral antibiotics
• Laboratory work-up
• Hydration to maintain urine output gt30-50cc/hr
• Strict I O
• CXR, ABG, Oximetry if respiratory symptoms
  present

15
Pyelonphritis in PregnancySummary of Management

• Mild/Moderate Pyelonephritis
• Initial hospital observation and work-up
• Parenteral antibiotics until discharge
• 14 day course of oral antibiotics
• Test of cure
• Severe Pyelonephritis
• Inpatient management
• Parenteral antibiotics
• Strict fluid management
• Support of secondary organ system involvement

16
Pyelonephritis in pregnancyPreterm Labor

• Tocolytics only when clearly indicated by
  cervical change, and uterine contractions not
  resolved by hydration and antibiotic therapy